* List 2 business references and 1 personal or school reference who are not relatives.

Reference Name

Years

Email

Phone

Relationship

Employee Responsibility to the Organization

Please be sure to read the following statements carefully.

I certify that all the
information I have provided on this application is true and complete to the
best of my knowledge. I understand that omitting requested information or
giving false information on my application in my interview (s) or in the
process of my pre-employment evaluation may result in rejection of my
application, withdrawal of a job offer, or termination, if I am hired.

I authorize investigation
of all statements in this application as may be necessary in arriving at an
employment decision, including a police/criminal record check from the
Wisconsin Department of Justice or any other appropriate Agency(s). I hereby
release from liability the employer(s) and its representatives for seeking
and furnishing such information.

I understand that if
offered a job, I will be required to:

Undergo a physical health exam, TB test, and communicable disease screening by a physician designated by the
Employer, which may affect decisions whether I can do the essential
functions of the job.

Undergo and pass a criminal record,
driving record and reference checks

And, after placement, complete and
receive certification in any and all employee training required and
requested by the Employer. I understand this training needs to be
competed within the first 90 days of employment and is a condition for
continued employment.

I understand that the
organization is an equal opportunity employer. The employer does not
discriminate in employment and no question on this application is used for
the purpose of limiting or excluding any applicant's consideration for
employment on any basis prohibited by local, state or federal law.

I understand that this
application does not represent an offer of, or contract for, employment. I
understand that employment with this company is "at will," and that no
guarantee of a job exists. If employed, I may terminate employment at any time
for any reason, and the company may terminate my employment at any time for
any reason not contrary to law.

This application is current
for only (60) days. At the conclusion of this time, if I have not heard from
the employer and still wish to be considered for employment, it will be
necessary for me to fill out a new application.

Clarity Care, Inc. is an equal opportunity employer. Qualified applicants are considered for employment and employees are treated without regard to race, color, religion, sex, national origin, age, disability, or any other basis prohibited by federal, state, or local law.

Clarity Care, Inc. is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, we invite you to voluntarily self-identify your gender, ethnicity or race. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

Check One:

Male
Female

(Step 1) Please select from one of the two ethnic groups listed below. If you are of Hispanic or Latino ethnicity, do not proceed to "Step 2". If you are not of Hispanic or Latino ethnicity, please continue to "Step 2" and indicate appropriate race:

Hispanic or Latino

Persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.

Not Hispanic or Latino

A person who is not Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.

(Step 2) Indicate the appropriate race only if you selected "Not Hispanic or Latino" in "Step 1":

American Indian/Alaskan Native (Not of Hispanic origin)

Persons having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment. It includes principle or enrolled tribes, such as Rosebud Sioux, Chippewa or Navajo.

Asian (Not of Hispanic origin)

Persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent. It includes Asian Indian, Chinese, Filipino, Korean, Japanese, Vietnamese, Burmese, Hmong, Pakistani, Thai or Other Asian.

Black or African American (Not of Hispanic origin)

Persons having origins in any of the Black racial groups of Africa. It includes African American, Afro American, Nigerian or Haitian.

Native Hawaiian and Other Pacific Islanders (Not of Hispanic origin)

Persons having origins in any of the original peoples of Hawaii, Guam, Samoa or other Pacific Islands. It includes Native Hawaiian, Guamanian, Chamorro, Samoan, Tahitian, Mariana Islander, Chuukese or Other Pacific Islander.

White (Not of Hispanic origin)

Persons having origins in any of the original peoples of Europe, the Middle East, or North Africa. It includes Irish, German, Italian, Lebanese, Near Easterner, Arab or Polish.

More Than One Race

VOLUNTARY DISABILITY INFORMATION

Clarity Care, Inc. is committed to equal opportunity in all aspects of employment for qualified disabled individuals. We ask your assistance in meeting this commitment by participating in this voluntary, self-identification program. The information you provide will be kept confidential. Please note that supervisors and managers may be informed regarding necessary accommodations; health and safety personnel may be informed if the condition may require emergency treatment; and government officials investigating compliance with the Americans with Disabilities Act of 1990, as Amended may be informed.

Please select ONE of the following:

I am not a person with a disability

I am a person with a disability (An individual with a disability is someone who has a physical or
mental impairment that substantially limits one or more major life activities; has a record of such
impairment; or is regarded as having such impairment.)

VOLUNTARY VETERAN INFORMATION

Under the Vietnam Era Veterans' Readjustment Assistance Act of 1974, (VEVRAA), Clarity Care, Inc. is required to submit a report identifying veterans in its workforce. Please indicate below if you qualify as a special disabled veteran, a Vietnam era veteran, or a veteran who served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized. You may identify yourself as a veteran now or at any time in the future. Please note that your response is voluntary. Declining to respond will not subject you to any adverse treatment. Information you provide will be kept confidential except where it is required to be disclosed by a civil rights enforcement agency, regulation, or law.

Please select ALL that apply:

I am not a veteran

I am a veteran; date of discharge or release from active duty:

I am a "disabled veteran." (A veteran who is entitled to compensation under the laws administered by the
Secretary of Veteran Affairs; would be entitled to such compensation but for the receipt of military retired pay;
or a person who was discharged or released from active duty because of service-connected disability.)

I am a "special disabled veteran." (A veteran who is entitled to compensation under the laws administrated by
the Department of Veteran Affairs for a disability that is rated at 30% or more, or rated at 10 or 20% if the
veteran has been determined by 38 U.S.C. 3106 to have a serious employment handicap; would be entitled to
such compensation but for the receipt of military retired pay; or a person who was discharged or released from
active duty because of service-connected disability.)

I am a "veteran of the Vietnam era." (A veteran who served on active duty for more then 180 days, and any
part of which occurred between August 5, 1964, and May 7, 1975, and was honorably discharged or released
sooner because of service-related disability.)

I am a "armed forces service medal veteran." (A veteran who, while serving on active duty in the U.S.
Military, ground, naval, or air service, participated in a U.S. military operation for which an armed
forces service medal was awarded.)

I am a "other protected veteran." (A veteran who served on active duty during a war or a campaign or
expedition for which a campaign badge has been authorized, under laws administered by the Department of
Defense.)